- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Professional | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |